In this interview, menopausal experts Diane Danzebrink and Dr. Sarah Ball are interviewed by Dr. Rebecca Lewis about HRT.
During the interview, they unravel the common and very actual myths around HRT, mostly to give women the opportunity to make an informed choice whether to take or not HRT. From HRT different formulations to the long term health effect, passing through the need of testosterone, we explain here in a very easy way all the benefits of taking HRT. These two doctors describe very clearly the long lasting effects of HRT and the benefits they exerts on overall health and symptoms.
What is HRT? Who needs HRT and what about periods?
HRT is usually two hormones combined: oestrogen- that is the one that we miss the most and it is the one that helps with the symptoms and the most protective for our bodies. If you still have your womb you then need progesterone as well (to protect the womb). For most women combined HRT is the best solution. For some women, there is also testosterone. If you still have your periods in perimenopause, you will have the type of HRT called cyclical; inducing the period.
If you have passed the point of having periods, and you are in full menopause, then just the combined one is enough for you. Sometimes you can hear stories of women that were not allowed HRT because they’re still in perimenopause. This is crazy because the earlier you start HRT the higher the benefits. Moreover, there is no reason to suffer the symptoms. Perimenopause, in fact, is like being on a rollercoaster
Sometimes people worry that taking HRT could just delay the menopause, is it true?
It does not delay it. Most of the myth came out after the WHA story, so many women because of the scaremongering of this study were taken away from HRT. This is a myth. The truth is that you are going to have symptoms if you were to be symptomatic anyway. It is very common for women to be told, there is no point in using HRT, you have to go through it at some point, better face it. But it does not delay the dread day. And years are variable, there is not enough research about it. We really don’t know how many years it can last, we have a range. Symptoms, for some women, can go on forever.
It is worth for a women to come off HRT?
HRT has double benefits, it has the symptomatic control, and the health protection for bones and heart, therefore the patients should be informed. Women that stay a long time on it they need to have annual consultation with their GP or healthcare specialist.
Another mantra, another myth out there is that you could only have it for 5 years. This is really old news. We know that this myth came out because there is a very small increase in the risk of being diagnosed of breast cancer if you have taken combined HRT for more than 5 years. But the benefits are a way more than the risk. Another myth is that you should come off by the age of 60, but there is no reason why you should do this.
Which are the health benefits of HRT?
Obviously, symptoms, but longer term benefits are bone health and heart health. But we are still in the learning process, we are learning every month new protective effects of HRT, for example on the brain. It reduces the incidence of diabetes, and reduces the overall risk of death. This is a big point.
What about people with family history of breast cancer?
Well, the idea is that if you have a family history of breast cancer you can’t have it and actually this is not correct. Women with family history has to be individualised and actually, the final choice has to be the one of the patient. Sometimes the problem is that for some women, who have another woman in the family with the history of breast cancer, they think it is almost inevitable. Having a family history does alter slightly your chances but it’s does not make the huge difference people think it can make. It is very important to give a detailed history of the family breast cancer, and what was the age when this relative was diagnosed. All this information is pivotal for the doctor to help you with an informed decision.
Some women need to go through the genetic test, but only 5% of women with breast cancer have this specific mutation. The main reason keeping women away from HRT is the risk related to breast cancer. And this is still something related with WHA study, that has since been discredited, some people still have this information in their mind. This is not surprising as there are many clinicians which are not aware.
Women need to be informed in order to be able to make a choice.
So, it should be clarified that there are other factors in lifestyle choices (no exercise, drinking too much alcohol, being overweight) that make the risk of breast cancer much higher than HRT itself. Women who had their womb removed and are on oestrogen only HRT, have this risk reduced. And this to stress the fact that is more the progesterone than the oestrogen on its own involved in increasing breast cancer risk.
Another worry of women taking HRT is formation of blood cloth, and we know, that this risk is higher if oestrogen is taken in tablet form, because it has to go through the liver to be metabolised. New formulation of HRT are patches and gels which goes through the skin, so it is basically impossible to get cloths. So even women that had previously had blood cloths can safely take HRT through the skin but they are told they cannot, which is not true. So, the effort here is to try to re-educate women and health professionals. Even women with migraines can safely take HRT through the skin (even migraine with aura). There is no known risk associated with it.
At some point, we think we sound like a broken record as we keep saying the very same things about how important and helpful HRT is also for your bone and heart. But the reality is, it comes down to education. We have a lot of studies now demonstrated that. It is a matter of communication and knowledge. HRT is important not only for very symptomatic women, but also for women who could cope with the symptoms but still need prevention for osteoporosis and cardiovascular diseases.
Another point is, shall women over the age of 60 be allowed to start HRT?
So, basically, we have this window, called the window of opportunity. Ideally, we would like to get HRT into women in perimenopause or within 10 years into menopause, so usually before the age of 60. Having said that, if we use the right type of HRT, this can still be useful even to women out of this window of opportunity. It can still be life changing, with the safest type of HRT. It has to be an individual discussion. Most women are using vaginal oestrogen which is very safe. And this is very important to point out as some women taking systemic HRT still suffer from vaginal dryness, so they really need local treatment to control all symptoms.
Another common doubt is: can women with endometriosis safely take HRT?
So, women in a severe stage of endometriosis, can benefit quite a lot from some progesterone for a couple of years. But endometriosis and fibroids are very interesting situation. People with both condition are told they can’t have HRT, but this is incorrect. It might be tailored a bit differently but still they can have it.
Should women be encouraged to use a lower dose of HRT with time?
We consider HRT as a ladder, and we start right at the bottom of this ladder as women needs are all different. Some might need more in a very short time, some might stay at the same level. Usually around 50, women reach a plateau in which the dose is pretty stable. Then, since your oestrogen receptor decreases sensitivity as you get older, you might start needing less oestrogen than before. So basically, coming back down from that ladder.
Oestrogen gels especially, are very good as it’s the women that controls how to use it. On the other hand, Mireena coil, which has some hormone in it, it is usually compared to HRT but it actually very different as there is no oestrogen in it. It does have progesterone, therefore can help with sleep and of course, not getting pregnant. If you have the Mireena coil then you can also take oestrogen from your skin. Since the Mireena coil is the gold standard for those women who has stopped child bearing, it often happens that women in their 40ies have it, and, since they don’t get any period they start wondering, how do I actually know if I am getting menopausal? Even if it does not seem easy, it not only about your period changing, but also small (or big) symptoms that weren’t there before. You need to be careful about all the different symptoms that can arise
And what about testosterone?
Probably the biggest myth about it is that it’s a male hormone. Another one is that it is just about libido. Neither is true. Instead it helps with bone health, muscle health cognition. We should be referring to it as a hormone, that men and women have. Something very strange is that it seems we need to ask permission to say: “we like to have libido and we quite enjoy having a sex life”. And we know sex is part of health in general and women need to be allowed to have this benefit as it can be life changing.